Complete Guide to Examination of the Nervous System
“The greatest wealth is health.”— Virgil
This system is different from the previous three in its methods of examination .
The examination can be vastly complicated . It is for PGTs but for you we ask you to do a simplified version .
The subheadings we shall cover are :
1. Higher Mental Function
2. Signs of Meningeal Irritation 3. Cranial Nerves
4. Motor system
5. Sensory system
6. Reflexes
7. Cerebellum and Co-ordination
There are many other headings too but we shall discuss those much later . Please also note that the single most important sub heading for you to learn is Ex
Is Examination of the Motor System …
Before learning about any other sub heading , learn this …
Then learn Examination of the reflexes …it carries equal importance and it essentially helps you to assess the motor system .
After that go to Examination of the Sensory System and Examination of the Cerebellum and Coordination
Finally go to Higher Mental Functions and signs of Meningeal Irritation .. When you write then down , follow the order mentioned above ..
But when doing them at the bedside , follow the order mentioned here because you need to do what is more important for you first … And your patients are just about always paralyzed ones ie .. suffering from motor dysfunction .
Let us start with the motor system …
EXAMINATION OF THE MOTOR SYSTEM
Before getting into this topic let us go over the issue of exposure .
EXPOSURE FOR NEUROLOGICAL EXAMINATION :
This is very important indeed … you could fail if you do it wrong .
1. For all patients , make or female , the limbs must be almost fully exposed .Exposure of the upper limbs upto the axillae is easy and hardly uncomfortable in all patients , make or female . But it must be done .
Exposure of the lower limbs is a problem because of chance of exposure of the private parts . We must expose the limbs upto the upper thigh and cover his / her genitalia at the same time so that he / she is relaxed and comfortable .
It is easiest if our patient is wearing a pair of shorts or underwear .
Trousers must be taken off . A lungi or saree must be rolled up to expose the limbs and cover the genitalia so that the patient feels relaxed .
Remember , that if your patient is not relaxed , there is no proper neurological examination . Sometimes you need to tie the saree/ lungi up like a tight dhoti ..
Only then can you proceed .
Never omit this step .
When we examine the motor system , we do so under 5 subheadings :
a. Attitude of the body and limbs b. Atrophy / Bulk of Muscles
c. Tone
d. Power
e. Involuntary movements
Among these , you simply must know power and tone … Either know them or fail. . Then go to attitude and atrophy ..
Involuntary movements is a very difficult topic and you could keep it for later . But when writing it down , always follow the correct sequence .
a. Examination of Attitude .
Attitude simply refers to the position of the limbs and body at rest .
We tend to be specially concerned about the limbs .
Attitude should be examined in the sitting , standing and supine positions , but for us , examination in only the supine position should be adequate.
We ask the patient to assume a supine and symmetrical position .
If he / she is paralyzed to an extent that he / she cannot then we do it for him / her .
Then we compare the position of the limbs .
We expect bilateral symmetry normally and a normal position in general .
Any abnormal position eg flexion or extension or lack of symmetry could suggest a neurological condition .
b. Atrophy
Atrophy refers to loss of bulk of muscles .
There is no special method here .
You have to expose the patient as explained above try to put him / her in a supine symmetrical position and then compare the limbs and also look at them one by one .
We are looking for obvious thinning of limbs , loss of muscle tissue , prominent bones .
It is easy to confuse generalised wasting and weight loss with neurological wasting .
If the wasting is asymmetric then we may compare the abnormal limb with the opposite normal limb .
For this purpose , we measure the circumference of the affected limb where we can see maximum wasting and compare it with the circumference of the opposite sides limb, the measurement being taken at the same level , ie wasting in the left forearm 7 cm distal to the olecranon .
So we have bony reference points :
Acromion for the arm , Olecranon for the forearm , ASIS for the thigh and the tibial tuberosity for the leg.
TONE .
Tone is the degree of muscle contraction at rest .
To assess tone we shall examine all four limbs …first the lower then the upper limbs . 1. The patient must lie supine and relaxed as described above ..
2. Exposure must be done also as mentioned above .
3. Ask the patient to relax , and not to move voluntarily .
This is an essential requirement because examination of tone requires passive movement of the four limbs ( ie you move the limbs and assess tone ) ..
Any active movement by the patient spoils any attempt at examination .
It is more practical to talk to the patient during examination to distract him / her ..
This works much better than an order or request not to move .
4. Lower limbs
We do the following in sequence :
We stand on the right side as usual , patient being supine.
a. We place our palms of both hands on the patient’s lower limb one hand above the knee on the lower thigh and one a little below , say over the middle of the leg and roll the lower limb . We don’t jerk it too fast as that might hurt , nor do we do it overcautiously in slow motion as that shall yield no finding .
But we do it a little quickly , a few rapid movements from side to side.
We can start with any limb but in case of hemiparesis , we do the normal limb first .
Remember comparing the abnormal with the normal by doing the normal first always applies to neurology and pulmonology and a bit to the GI system.
We feel the degree of stiffness while rolling the limbs and look at the movement of the foot at the ankle joint .
Increased tone causes the entire limb to move as one like a log of wood .
Decreased tone causes floppiness .
Normal tone is recognised only after some experience . All you can do is practice on normal people for this .
b. We stand where we are and place the fingers of both our hands below the knee joint ,one side at a time as described above .
We face the feet as mentioned above .
Now we rapidly pull the knee up but not to the extent of picking the entire limb off the bed ( A few inches is often enough ) and let it go and watch the movement .
If the tone is increased , the limb behaves somewhat like a log of wood .
If decreased , the foot remains on the bed and on release it flops back to the bed . Normal …you need to see this for idea.
c. Stand where you are , hold the patient’s heel and pick up one limb by say 6 inches and then let it fall to the bed and observe the movement .
This is often done by seniors but because it might hurt I’ll advise you to skip this particular one .
d. Now we examine individual muscle groups eg flexors of the hip etc .. ( not individual muscles ..)
You are instructed to examine the flexors and extensors of the knee joint is the hamstrings and the quadriceps .
This is done by passively stretching the muscle .
In other words , we must extend the limb at the knee joint to assess the tone of the flexors of the knee joint and flex the knee to assess the tone of the extensors .
This is because extension at the knee shall stretch the hamstrings while flexion shall stretch the quadriceps .
So to test the hamstrings , we..
1. Attain the necessary position which is flexion .( Remember we need to extend the limb to test the flexors and this should be started from a flexed position , you can’t extend a limb when it is already extended )
And it must done passively is by you not the patient . Even if the patient is big and heavy .
2. Now place one hand over the hamstrings on the side you are testing first ( this hand is to feel the muscle and give mechanical support , it is the less important hand ) and hold the front of the shin with the other hand ( this hand shall both extend the limb and feel the resistance to extension offered by the tone of the hamstrings when they are stretched by extension , this hand is all important here )
3. At the same time pick the limb slightly off the bed with the all important hand and extend the limb .
4. Do it with some speed to appreciate the resistance better .
5. Your first chance is best chance. Moving it several times can reduce the findings .
6. Compare with the opposite side , normal side first .
7. Correlate with other findings.
Learn to think in your feet if you want to excel in clinics .
Now that the hamstrings are done we test the quadriceps. The steps are the same
We place the important hand over the middle of the shin as described above and place the other less important hand over the anterior aspect of the thigh and proceed to move the limb from an extended position to a flexed one , passively .
Note that the supine limb is already extended .
Always compare
Extensor with extensor on both sides and then flexor with flexor .
It is a really gross error not too …and normal side first unless both sides are abnormal when it doesn’t matter .
For the upper limbs
We go directly to individual groups .
Here , we do the extensors and flexors of the elbow joint. We proceed exactly as in case of the lower limb
Our main , important hand holds the supinated forearm to perform the movement .
Our lesser hand is placed over the muscle group to be tested . Over the anterior aspect when testing the flexors and the posterior when testing the extensors .
The only additional examination here is examination of clonus .
This is done exclusively in the lower limb , and if present is a sign of greatly increased tone .
Clonic movements are spontaneous alternating flexions and extensions which are stimulated by sudden stretching of a hypertonic limb .
We see
a .ankle clonus
b.patellar clonus
Ankle clonus
1. Patient us supine
2. Place one the palm of one hand over the sole of his / her foot .
3. Place the other hand in the popliteal fossa ( behind the knee) and lift the knee off the bed but let the heel rest on the bed , relaxed .
4. Now suddenly using your hand on the sole , dorsiflex the foot and at the same time using the same time pick it up a little off the bed so that heel is just a few inches of the bed (2-3 inches is fine ) .
The other hand below the knee remains steady throughout .
5. The dorsiflexing hand is held steady ..the dorsiflexion and hence the stretch of the tendoachilles is maintained … Tight but not with all your strength .. that actually prevents movement.
If ankle clonus is present , the foot dorsiflexes and plantarflexes alternatively as long as the stretch is maintained in severe cases or dies down after a few contractions .
6. such movements in sequence gives a finding of ankle clonus .
Patella clonus
1 . Stand on the right side .
2. Place your left hand over the right patella ( this is convenient ) and rub it across the patella upwards ,pulling up the loose skin that overlies the patella .
3. Now , ensuring that the loose skin is neatly tucked away , above the patella by your left hand ,use your left hand to suddenly ( not too hard ..this hurts and not for a great distance , hardly an inch ) push the patella down .
This movement stretches the ligamentum patellae and may cause a spontaneous upward and downward movement of the patella called patella clonus .
Ankle clonus us really quite common …you don’t see much because you forget to look and because your technique is often faulty .
Patellar clonus is rare but still look for it .
POWER
Examination of power along with tone and reflexes is most important for your exams .
It really requires demonstration so see videos …
Meanwhile I shall try to highlight the main points and describe what to do .
A. Patient position
1. Supine or Standing / Sitting
2.Most of your patients shall be unable to stand so you have to do it supine .
3. The lower limb is largely tested supine.
4. It is easier to do the upper limb sitting / standing if the patient can manage to . B. EXPOSURE
As described above .
It is essential . Don’t forget about it or ignore it , specially in an exam . You must see the limbs you are examining .
C. What to examine .
Actually , we examine power in the following muscle groups :
1. Limbs 2. Trunk 3. Bulbar 4. Facial 5. Neck
For you let’s stress on limbs .
Facial , bulbar and neck shall be covered under the broad heading of cranial nerves . Let us do trunk later .
EXAMINATION OF POWER IN THE LIMBS :
We examine muscle groups rather than individual muscles .
It is certainly possible to examine individual muscles but that level of detail isn’t necessary right now , specially in the very beginning . Let’s learn to assess muscle groups . Later we might also learn to assess the power of individual muscles .
GROUPS assessed in the UPPER LIMB .
1. Abductors of the Shoulder Joint
2. Adductors of the Shoulder Joint
3. Flexors of the Shoulder Joint
4. Extensors of the Shoulder Joint .
1. Flexors of the Elbow Joint
2. Extensors of the Elbow Joint.
1. Dorsiflexors of the Wrist Joint
2. Palmar flexors of the Wrist Joint .
So eight muscle groups in the upper limb . GROUPS assessed in the LOWER LIMB
1. Flexors of the Hip Joint
2. Extensors of the Hip Joint 3. Abductors of the Hip Joint 4. Adductors of the Hip Joint
1. Flexors of the Knee Joint
2. Extensors of the Knee Joint
1. Dorsiflexors of the Ankle Joint
2. Plantar flexors of the Ankle Joint
So 8 again .
The small muscles of the hand shall be discussed separately and at a later date . They are not so important for you right now .
SOME GENERAL PRINCIPLE OF POWER EXAMINATION :
1. The patient must be conscious , alert and cooperative .
There is no proper way to examine power in a patient who cannot follow commands .
This is why we start with Higher Mental Functions .
If this is impaired , so is our subsequent assessment .
2. The patient moves his / her limbs actively .
We observe the movement and then oppose it for an assessment of power . ( Remember Tone was based on passive movement )
3. We can do one of the three
a. Ask the patient to perform the movement and then try to oppose it .
ie .. a patient flexes his right elbow joint and we try to assess the power of the right elbow flexors by trying to extend that limb by force .
This method makes it easy for the patient but we don’t often use this except while assessing power in the small muscles of the hand .
b. We oppose the movement from the very beginning .
ie ..We hold the right upper arm in extension at the elbow and he / she tries to flex it against the resistance we offer .
This is most difficult for the patient but is often done .
c. The patient holds his / her limb having partially completed the movement and then attempts to complete the rest against resistance .
This too is commonly done .
INDIVIDUAL GROUPS :
This part is going to sound odd without a video but let’s try anyway.. 1.Flexors of the Shoulder
The patient flexes his elbow to about 90 degrees .
Then he tries to move his entire arm forward and medially , not straight forward but 30 degrees medial because the scapulae are tilted to face 30 degrees medial .
We oppose the movement by gripping his arm from behind , hold his arm and pull backwards opposing his/ her attempted forward movement . ( It is forwards and 30 degrees inwards )
2. Extensors of the Shoulder .
We do the opposite of what is described above .
The difference is that we stand in front of the patient and try to prevent his backward movement of the arm . ( It is backwards and 30 degrees outwards .)
3 . Abductors of the Shoulder Joint
The patient holds his/ her upper limb absolutely straight and tries to abduct it ie ..it should eventually reach the side of his / her head .
You oppose by applying pressure over the lower part of the arm , just above the elbow .
4. Adductors of the Shoulder Joint .
Do the opposite of the above .
The patient starts from his / her hand above his / her head and tries to draw it towards his / her body . You oppose the movement holding the limb just above the elbow .
5. Flexors of the Elbow joint .
Oppose the movement by pulling it ,your hand being just proximal to the wrist .
6. Extensors of the Elbow Opposite of above .
7. Palmar flexion .
The patient holds his hand stiff and tries to flex his wrist in the direction of his palm . You oppose with your palm by applying pressure on his / her palm .
8. Dorsiflexion of the wrist
Opposite of above ..
You apply pressure on the dorsum of his / her hand this time .
9. Flexors of the Hip
This requires a particular posture which I simply cannot describe properly .. see the video please .
10. Extensors of the Hip
The patient is prone for this one . ( He / she is supine for all other lower limb power assessment )
He / she tries to extend the lower limb from the hip in a prone position ie lift it off the bed …you oppose by applying pressure on the lower part of the back of the thigh above the popliteal fossa.
11. Abductors of the Hip
The patient tries to move his / her entire lower limb outwards just above the bed …you oppose by pushing it ,hand kept over the lower thigh , outer aspect .
12. Adductors of the Thigh
Opposite of the above .. You pull instead of push
13. Flexors of the knee joint
The patient tries to flex his / her knee .
You grip above the ankle and try to pull the limb straight .
14. Extensors of the knee
Opposite of above ..
This time you push instead of pull .
15 .Plantar flexion
The patient tries to plantar flex his / her foot .
You oppose by pushing in the opposite direction b, your hand over his / her sole .
16. Dorsiflexion of foot
Opposite of the above .
This time you place your palm over the dorsum and pull his / her foot down to prevent dorsiflexion.
Also note that : Grades of power
0. No power ..no movement at all
1. Flicker of contraction …no movement at any joint
2. Movement with gravity eliminated .ie movement across the bed is possible but no elevation is possible without help .
3. Against gravity but not against resistance .
4. Against resistance but less than normal .
5. Normal
When testing power , always ask the patient to do the movement in front of you first without any opposition from your side .
If he can do it well , it is at least 3 if not grade 4 or 5 .
The you apply resistance to get the proper grade .
Shall send pictures to clarify this ..
Read and do what you can
It’s actually quite easy …just needs a demonstration .
Cardiovascular Examination: The Complete Guide
INVOLUNTARY MOVEMENTS
This is more for post graduates than for you ,at the bedside.
Clinically , you must know what fasciculations are and what their differences are from fibrillations ( which you cannot see with the naked eye ) .
You should also know about flexor spasms .
Shall show you these when you get back and shall discuss them with along with the relevant long cases .
EXAMINATION OF THE SENSORY SYSTEM .
The method is relatively easy but getting the proper findings depends on how much your patients can cooperate .
It is slow and needs patience .
When we examine the sensory system , we are referring to general senses eg touch , pain , temperature and the like .
Special senses are discussed with their respective special organs , mostly the cranial nerves .
We shall examine the following sensory modalities : 1. Fine touch
2. Crude touch
3. Pain
4. Temperature
5. Vibration sense
6. Joint position sense
The first four are examined in exactly the same way except that the instrument is different .
The last two have a somewhat different method .
After these 6 , we shall examine Cortical Sensation
Examination of fine touch , crude touch , pain and temperature .
The respective instruments are :
1. Fine touch – a wisp of cotton ie a small dry piece of cotton with the tip drawn to a point .
2. Crude touch – The blunt rounded end of a board pin .
3. Pain – The sharp end of the same pin .
( The sharp end that several hammers carry is not going to do .. please use the pin .)
4. Temperature – Ideally ,test tubes with hot and cold water .Ideal temperatures are : cold 7 degrees Celsius and hot 43 degrees .
Such test tubes are often not available , do we use the tuning fork ( it is cold metal object ) for assessment of response to cold and rub our hands together vigorously to create a warm temperature )
THE METHOD
1. The patient requires to exposed and supine as for the motor system but his / her trunk must also be exposed as was done for the GI system .
2. Consent for examination must be taken . This would apply to any medical examination or procedure .
3. Explanation :
The patient needs to understand exactly what you want him/ her to feel .
This is more a demonstration than an explanation .
If you want to examine fine touch , you have to show him / her what fine touch is .
Thus,
a. First we have to determine which areas have preserved / normal sensation .
This should be obtained easily enough from the history . In most patients the history and the sensory findings match. If there is no complaint of sensory loss there usually isn’t . But then there are exceptions to the rule .
So find a normal area from history and use to explain what you want .
b. Let us say eg we are examining fine touch .
We create a wisp of cotton and then touch his / her normal area say forehead in a particular patient . His/ her eyes should be open here to let him / her understand what is expected of him / her . This area is called the reference area / point .
4. The actual test
Once he/ she has understood what fine touch is he / she must close his / her eyes . The test is always conducted as such to avoid the patient seeing you examine and giving you false positive responses .
5. You tell the patient that you will touch various sites over his / her body in exactly the same fashion as you did over the reference area .
The patient , with eyes closed shall try to notice:
1. Whether he / she can feel anything or not
2. If he / she feels the sensation demonstrated ( fine touch in this example ) whether it is of the same intensity or less than over the reference area / point .
3. He / she has to repeat this until the examiner has finished examining the whole body ie almost all dermatomes ( a dermatome is an area of skin whose sensation is supplied by a particular sensory nerve root ) .
6
A. The examiner proceeds from the feet upward towards the neck .
B. The examiner compares right with left at the same level before ascending to the next dermatome.
This should be clarified by example :
Our patient is having his / her fine touch examined. Explanation with the help of the reference area is complete.
Now , the examiner touches the dorsum of the right foot with the wisp of cotton in exactly the same way as he touches the patient’s forehead ( reference area ) and waits a few seconds for a response .
The patient might
a. Reply in the affirmative and say he/ she felt something just like over the area of reference .
OR
b. Say that he / she felt something like over the area of reference but with a lesser intensity .
OR
c. Give no response because his / her eyes are closed and he / she felt nothing .
The response at this lowest level on both sides is noted and then we shift to the next level / dermatome ie say from dorsum of foot to lower aspect of leg medially and the process is repeated until we reach the neck .
If history suggests hemisensory loss , we always start with the normal side while doing the test ( normal first is a basic rule which has been mentioned umpteen times ) .
7. Asking a patient whether he / she actually felt something is necessary sometimes . However ,if you ask repeatedly some patients sat yes repeatedly spoiling your test
Some people are still confused after your explanation and need to be spoken .
Some sick and elderly patients actually doze off during this long and boring procedure so talking to them keeps them alert .
8. Please explain properly.
a. Pain for example must be painful and not a very gentle fine touch with a pin .
b. At the same time you can pierce the patient’s skin by accident in your zeal to produce pain so ask him / her gradually increasing the force whether it actually hurts or not .
c. Hold the pin with your index and thumb in the middle of the shaft without supporting the blunt end with a finger . This allows even pressure.
d. Please read up your dermatomes or at least see the book for knowledge of dermatome distribution.
Now let us examine vibration sense and point position sense .
1. Joint position sense
This is essentially proprioception or knowledge of the position of one’s body parts
We classically test it the the interphalangeal joint of the great toe , though we can test it at otherjoint .
METHOD :
1. Maintain necessary exposure
2. Ask patient to relax
3. Hold base of great toe at the sides of the base ( not the upper and lower surfaces ) with one hand .
4. With the other hand hole the sides of the tip of the toe and move it above in a plantar direction and then below in a dorsiflexion direction.
Let the patient see and understand this .
Now we repeat the test with eyes closed
If the patient gets at least 6 answers right in sequence he / she has normal joint position sense .
Vibration sense
We use a tuning fork here , of 256 Hz as we used in ENT classes .
The method is similar to what we did with fine touch , crude touch , pain and temperature with the following differences :
1. Vibration is easily damped by soft tissue so we can only place the tuning fork over bony surfaces .
The reference area is usually the forehead or the scalp .
If necessary it might be taken over the Wrist , Olecranon or Ankle .
2. We use particular fixed bony points over the lower limb ,upper limb and trunk .
Lower limb
We start distally as for other modalities and proceed proximally .
1. Tip of the toe
2. Medial aspect of ball of great toe 3. Medial malleolus
4. Tibial tuberosity
5. Anterior Superior Iliac Spine .
Upper limb.
This limb isn’t commonly tested but if necessary we use the following points 1. Wrist
2. Olecranon
3. Acromion
Regarding the process
We always start from the tip of the toe .
However vibration testing is different from the others in that if it is normal distally it must be normal proximally .
In other if the vibration sense is normal at the great toe ,it shall be normal throughout the lower limb .
If it is abnormal till the ASIS , then we have proceed up the back of the spine , spinous process by spinous process before also doing the upper limb.
Shall finish cortical sensation tomorrow and move on to other area too .. Bye for now
Cortical sensation
You only feel sensations when the sensation felt by your sensory receptors is processed by your sensory cortex .
In other words ,even if your sensory receptors ,nerves and pathways to the cortex are intact ,if your sensory cortex is damaged you can have difficulties .
Often these difficulties are subtle and need clinical tests to identify them . Some simple tests are described briefly below .
1. One point localisation
a. We touch a part of the patient’s body with a compass / pin
b. The patient’s eyes should be closed while this is done .
c. Now he / she is asked to localise that point with a finger tip .
d. Normally, this is achieved easily enough. This is one point localisation .
e. The test is done with eyes closed after the stimulus is demonstrated to the patient and the test is explained .( gently )
2. Two point discrimination
a. We use a divider ( from our school geometry box for this test ) .
b. The principle is that we can differentiate between two points / stimuli provided that they are not too close together .
c. The distance between which we can differentiate depends on the sensitivity of the part of the body .
Our fingertips can differentiate between a few millimetres while on our trunk or back the distance is a few centimetres.
d. Thus we set the divider to the appropriate distance and see if our patient can differentiate between two adjacent stimuli at the same time .
e . The test is done with eyes closed after the sensation to be used is demonstrated to the patient and the test is explained .
3. Sensory inattention
a. Using two pins we touch the same part of the body on either side .
b. First we touch both sides separately and with his eyes open so that he understands what stimulus is being used .
c. Now we touch both points simultaneously with his / her eyes closed and ask him/ her on what side he/ her felt anything .
d. Normally , he / she should feels both but incase of a lesion of the sensory cortex he/ she may only feel it on one side .
4. Graphaesthesia
a. We write a letter on his / her back in a language he / she is familiar with or draw a simple shape eg circle , square and ask him / her to identify it .
b. Normally it is possible but it may lost in case of a sensory cortical defect .
c. After explaining the test , we conduct it with the patient’s eyes closed .
5. Stereo gnosis
a. We explain the test to the patient and then conduct the test with both his / her eyes closed .
b. We put familiar objects into his / her hand , one by one and ask him / her to identify them …eg a coin , pencil ..
This is all for sensory for now .
Now let us come to
SIGNS OF MENINGEAL IRRITATION
These are acute signs typically found in meningitis .
Such patients shall hardly come to your exam hall but are very common in real life in the ward and so the signs cannot be missed .
There are three signs of Meningeal Irritation .
1. Neck Rigidity
a. Normally your neck is fairly supple and it can bend forward so that your chin can touch your chest .
To test this we follow the following steps .
a. Ask the patient to relax and allow to passively flex his neck forwards towards and often upto his / her chest ( if possible without discomfort or damage ) .
A little reassurance may be necessary here .
b. Place your hands side by side , palms facing forward so that you are supporting the upper part of the neck and the occiput of his /her head .
The back of the neck (the upper part should rest over the palms while the occiput should rest in the fingers .
c. Now flex your fingers at the metacarpophalangeal joints a few times , slowly and gently to see how far forward the neck flexes and how much resistance is required .
Normall there is not much opposition .
d. Incase the neck is rigid ,it feels very stiff and difficult to flex and it is difficult to reach the anterior chest wall .
e. Similar difficulty is often encountered in elderly people suffering from cervical spondylosis .
However ,this can be easily differentiated by putting your hand on his /her forehead and rolling the head gently from side to side to exclude a side – to – side movement restriction which is present in spondylosis or any cause of bony fixation and absent in meningitis.
f. Ideally we examine for neck rigidity plus we do the side-to – side manoeuvre to exclude spondylosis .
g. The patient should be supine during the test .
2. Kernig’s Sign
a. The patient is supine during the test .
b. We ask the patient to relax and to allow passive movement of his / her lower limbs and to tell us to stop if it hurts.
c. We pick up anyone lower limb and hold it with the hip and knee both flexed at 90 degrees . One hand should hold the thigh and the other should be one the leg .
d. Now , holding the patient’s thigh steady , and looking at the patient’s face for any sign of pain (remember it is a potentially painful manoeuvre ) , we attempt to straighten the knee thus extending it while the hip remains flexed at 90 degrees .
e. Any pain plus restriction to movement is a positive test ( let us remember that most adults cannot allow the full stretch even without pain …pain is a very important finding here … So do it gently )
3. Brudzinski’s sign
There are two parts here :
A. The Brudzinski’s head sign B. The Brudzinski’s leg sign
The head sign
If an attempt to examine neck rigidity causes a spontaneous flexion of one knee , even if slight , even one sided , it is a positive test .
The leg sign.
An attempt to examine Kernig’s sign on one side causes spontaneous flexion , even if slight of the other knee …this is the leg sign .
EXAMINATION OF THE NERVOUS SYSTEM CEREBELLUM / COORDINATION
Coordination is a difficult topic and includes not only the cerebellum ,but also sensory input eg proprioception and motor function .
We shall look at a list of cerebellar tests.
If abnormal findings are noted it usually indicates cerebellar dysfunction but proprioceptive loss can often mimic cerebellar disease .
We shall discuss how to make the difference while discussing cases ..
Let’s go to the tests and findings of cerebellar dysfunction .. Prerequisites before testing :
1. The patient must be alert , conscious and cooperative or it will simply not be possible to do cerebellar testing .
The tests are all based on the patient following a command and you observing the resultant movement / attempt at movement . This is why we always start with Higher Mental Functions .
If you can’t follow commands … neurological testing becomes rather difficult .
2. He / she must have at least 3/ 5 power or it is not possible or practical to do cerebellar testing .
The pyramidal tract is the final common pathway for all movement .
Before the final impulses which make you move as you wish reach the various parts of your body via the pyramidal tract the impulses flow through the cerebellum where they are fine tuned to give an accurate fine tuned movement .
In other words no cerebellar support makes you very clumsy indeed … the medical term for this condition is ataxia .
However ,weakness less than 3/ 5 means you can barely lift yourself off the bed but are not totally paralysed either , a state which can be confused for clumsiness at times .
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So a power of 3/5 is a prerequisite for proper cerebellar testing . 3. Do sensory testing before cerebellar testing .
You move based on your requirements and that is decided by your sensory input , specially proprioception . In other words … If you can’t see you shall difficulty in walking or moving , if you can’t feel the ground beneath your feet you shall feel unsteady , and if you don’t have proprioception ( knowing where your limbs and trunk are ) , you shall have difficulty as well … in a word , lack of sensory input makes you clumsy but this is called sensory ataxia , and can be differentiated from cerebellar ataxia on careful testing which we shall discuss later with patient discussions.
This is why we do cerebellar testing after motor , sensory and reflex testing .
THE TESTS :
Not all tests have names , some are described.
UPPER LIMB TESTS
1. The patient stands up ( sitting is allowed if necessary instead ) and holds his/ her upper limbs outstretched infront of him / her , palms facing down .
Now ,tap both hands with force and observe the result .
Incase of a cerebellar lesion , the affected limb bobs up and down before it finally settles back in the initial position , that too with difficulty .
2. Finger – nose test
a. The patient sits or stands .
b. He / she hold his upper limb outstretched to the side at 90 degrees of abduction . c. One finger , the index usually is outstretched while the others are folded in .
d. He/ she flexes the elbow but the arm remains in its abducted state and touches the tip of his / her nose with the tip of index finger , holds it there for 5 seconds and then outstretches it again.
e. The movement is repeated several times preferably with speed . f. Any inaccuracies / clumsiness favour cerebellar disease .
g. It can be made more difficult and hence more sensitive by doing a modification called the finger – finger – nose , where he / she moves his fingertip between his / her nose and the examiner’s fingertip ( usually index ) which is held in a slightly different position each time . This can reveal subtle disease .
3. Past pointing
If the patient while doing a finger nose missed the nose repeatedly and hits his / her face ,it is
probably due to past pointing also called dysmetria – an inability to judge distance .
4. Intention tremor
a. A tremor is spontaneous to and fro oscillatory movement of a body part .
b. There are several types and subtypes but an intention tremor is one which occurs only on attempted movement .
c. It is also called action tremor or kinetic tremor .
d. When the patient tries to do a finger – nose test or when he / she reaches for an object , the moving hand starts shaking as it approaches the object .
It stops only on withdrawal or stopping the attempted movement .
e. Severity is variable .
5. Rebound phenomenon
a. The patient pulls his / her forearm, flexed at the elbow , towards his / her face against the examiner’s forearm interlocked with the patient’s forearm and also pulling with great force .
b. The examiner’s other forearm is in front of the patient’s face as a shield .
c. If you suddenly withdraw your pulling force , the patient’s forearm is flung involuntarily towards his face and blocked only by the examiner’s other forearm.
d. This lack of brakes is called rebound phenomenon .
6. Dysdiadochokinesia
a. This word simply means absence of ‘ rapidly alternating movements ‘
b. To test it’s presence ,the patient puts one palm still and palmar surface upwards and quickly slaps it with the other hand , in a regular fashion with about the same amount of force each time ,alternating each time between the palmar surface and dorsal surface of the striking hand .
The other hand remains still .
c. The presence of any assymetry / clumsiness is a positive result for the presence of cerebellar disease .
LOWER LIMB TESTS
1. Heel – shin test
a. We do it supine.
b. It is similar to the finger-nose test in the upper limb.
c. The patient elevates his / her lower limb above the bed and brings his / her knee down on the same sided patella and then moves it along the anterior border of the tibia ( shin ) upto the great toe of the foot
d. Any clumsiness is to be watched for carefully . 2. Pendular knee jerk .
a. We observe the knee jerk but in a sitting posture ( like we used to do in the physiology class ) .
b. Normally , there is just one to and fro movement of the leg .
c. If this to and fro movement is more than 2 and a half times it is s pendular knee jerk .
3. Stance
a. The cerebellar patient often has difficulty in standing straight and a tendency to fall to one or both sides or too sway .
b. His / her feet maybe placed far apart .
4. Gait .
a. Broad – based gait ( ie distance between medial malleoli is more than 12 cm ) b. Swaying to one or both sides is there , sometimes falling too .
5. Tandem walking / Heel – toe walking .
a.This is the practice of walking along a straight line with the heel of the foot in front in contact with the toe of the foot behind with every step .
b. Cerebellar patients have difficulty . OTHER TESTS
1. Tone
Cerebellar disease can cause hypotonia .
2. Titubation
a. Spontaneous head – nodding can be seen sometimes .
b. It is called titubation .
3. Staccato Stuttering speech
a.This needs demonstration …please see a video .
b. The syllabi of the words are separated and sound like individual words .
c.To test this we ask him / her to say a particular sentence .
d.The favourite sentence in Bengali is ‘ Amar Bari Kodom tola ‘
e. The favourite English expression is ‘ British Constitution ‘ .
Shall continue tomorrow. Bye for now
EXAMINATION OF THE NERVOUS SYSTEM REFLEXES
There are two types of reflexes ,
1. Superficial Reflexes
2. Deep Tendon Reflexes
DEEP TENDON REFLEXES
We examine 3 in the upper limb and 2 in the lower limb :
UPPER LIMB
We examine the following three in the upper limb in the order mentioned here.
1. BICEPS REFLEX
a. This can be examined in a sitting posture but is better examined supine when better relaxation can be achieved .
Both arms rest such that the elbows are on the bed , not under any strain ,on either side of the body , just next to it while the hands lie on the abdomen close to the umbilicus on either side .
b. The patient must be informed that he should not move during the test as has been described above . Although , distracting him / her with small talk often works really well .
c. This posture applied to biceps , supinator and triceps reflexes .
d. The next step common to all is exposure of the muscle to be examined . You must see the muscle contract .
e. Now place your finger or thumb over the biceps tendon in the cubital fossa ( if necessary adjust the degree of flexion of the biceps to create enought room to use your hammer .
f. You must press down with some firmness over the biceps tendon , because this is a stretch reflex , this stretch improves the response.
g. Now strike your index finger / thumb with your standard percussion hammer .
h. Regarding proper use of a percussion hammer in neurology
1. Your wrists should be flexible so that the weight of the hammer determines the force of the stroke , not your physical strength .
2. Try to hit everytime with almost exactly the same force and at the correct point .
3. After hitting , the hammer stays for a few seconds until a response is seen or not seen . You do not pick up the hammer as in chest percussion .
4. Hit along the length of the tendon for a better result .
i. Now strike the tendon as described above .
SUPINATOR REFLEX
a. Assume the posture and exposure as described in A .
b. Now pick up the right hand of the patient with your left hand ( assuming that you are right handed and are holding the hammer in the right hand )
c. Hold the hand in a handshaking grip and make the forearm semi prone and apply some stretch to the radial aspect of the forearm .
d. We hit the small tendon of the supinator , 5 cm proximal to the radial styloid as mentioned above .
TRICEPS REFLEXES.
a. Posture as mentioned .
b. Now hold the wrist and pull his /her forearm across his / her chest to get create stretch in the triceps tendon and then strike with the hammer as mentioned above.
LOWER LIMB. There are two
1. KNEE JERK 2. ANKKE JERK
KNEE JERK
a. The patient must be supine and relaxed .
b. Exposure upto the upper thigh .
c. The lower limbs must be resting on the bed with heels on the bed and knees and hips flexed , knees about 90 degrees .
d. You place your back of the hand / forearm in the popliteal fossa and support the weight of the entire limb , heel remaining on the bed however .
e. Locate the patellar tendon …this is usually pretty obvious unless the patient is a bit overweight .
f. Strike with the percussion hammer as described above . g. Observe limb movement and or muscle contraction .
2. ANKLE JERK
a. The posture is a bit different ..
The patient is supine .
The lower limb is extended and a bit externally rotated at the hip , a bit flexed at the knee and the lower end of the tibia just above the lateral malleolus is placed on the opposite lower limb which is kept straight
b. You hold the toes of the ankle to be examined with your left hand and dorsiflex that foot with some force thereby stretching the Achilles tendon .
c. Though this feels awkward ,strike the Achilles tendon with your tendon hammer as smoothly as possible ,being totally in line with the tendon isn’t possible so don’t bother too much .
Shall continue tomorrow ..
This is very very important and an exam favourite …do practice from the videos Bye for now
EXAMINATION OF THE NERVOUS SYSTEM REFLEXES SUPERFICIAL
We shall do three Superficial Reflexes :
1. Plantar reflex
a. The patient should be supine.
b. He / she should be warm and relaxed .
c. Explain to the patient briefly what is going to be done to allay any anxiety .
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d. Check the sole of the foot for presence of sensation . e. Check the great toe for free movement .
f. Now hold the two malleoli with the index and the thumb of the left hand firmly , but without touching or squeezing the ankle joint .
g. Now procure s blunt instrument to scratch the sole of the foot ..
1. It must be blunt to avoid injury .
2. Ideally , it should be a key ; please avoid the point of your hammer which is often extremely
sharp .
h. Now being to scratch the sole of the foot , starting at the lateral border ,near the heel and then proceeding slowly and steadily up along the lateral border of the foot and then turn along the bases of the toes from the smallest toe upto the ball of the second toe . The ball of the great toe is to be avoided .
i. The scratch must be slow and deliberate …it is by definition a noxious stimulus .
j. Often a response is obtained early after a little bit of scratch …the scratch may be stopped once a response occurs .
k. If no response occurs , repeat the entire process but with a bit more force . l. Interpretation shall be discussed later with cases .
2. Abdominal Reflex
a. Expose the anterior abdominal wall from the xiphisternum till the inguinal ligaments , the patient being supine .
b. Now using a lighter instrument ( your long handled percussion hammer is ideal for this ) , we scratch the abdomen three times on either side from above to below .
c. The scratches must be light , swift and should not produce any permanent impression on the skin .
d. The scratches are delivered from lateral to medial .
e. The first scratch is a little below the subcostal margin ..
The second one starts a little below where the upper scratch started , and nearer to the umbilicus and proceeds towards the umbilicus ..
The third one starts a little below the 2 nd one and proceeds a little above and parallel the inguinal ligament .
Normally, this is present and lost during UMN lesion .
3. Cremasteric reflex
a. We scratch the inner thigh from the medial aspect to the lateral aspect ,with our instrument used for the abdominal reflexes.
b. We need to expose the genitalia to watch them move upwards momentarily incase of a positive test .
EXAMINATION OF THE CRANIAL NERVES :
1 ST CRANIAL NERVE THE OLFACTORY NERVE
This is easy to test but inconvenient to arrange for and hence is usually not asked to be demonstrated but you can still be asked how to do it .
a. We are trying to look for loss of sense of smell , reduced sense of smell ,or abnormal perception of smell .
b. The most common cause of loss of sense of smell is nasal obstruction which is not a cranial nerve condition at all ,so it must be searched for and excluded first .
c. We can exclude nasal obstruction by the following ways :
1. Use Thudicum’s Nasal Speculum as you did in the ENT ward to do an anterior rhinoscopy … This is usually not available so we use the next two methods …
2. We just upturn the tip of the nose with a finger and use a torch to examine each nostril for any obvious obstruction .
3. Ask the patient to occlude one nostril at a time with his / her fingers and sniff strongly with the other nostril in front of the examiner …this can easily reveal the presence of nasal obstruction. If there is no obvious obstruction , we can proceed to test the olfactory nerves .
4. We need 2 or 3 small bottles , preferably glass , with a stopper to hold odourous substances to used for testing.
5. The substance used should not be pungent or irritant in anyway , because such substances stimulate the trigeminal nerve rather the olfactory nerve .
Any pleasant smelling substance can be used .
6. Each nostril is tested separately . When one nostril is being tested , the patient occludes the other nostril with a finger firmly .
To test the examiner holds the bottle under the nostril being tested with stopper open .
The patient takes a few good sniffs .
Then he repeats the process with the other nostril .
7. The patient is not allowed to see the contents of the bottles .
8. Now ask three questions :
a. Could he / she actually smell anything on one or both sides ? …if not then anosmia on that side or both sides
b. Was the sense of smell reduced on one side ? .. hyposmia
c. Was there an abnormal perception of smell ? ie .. perceiving a pleasant smell as an unpleasant one ?… This is called hyposmia ..
9. Now repeat the entire process with a different substance
And ask one extra question in addition to the above three ..
Could he differentiate between the two substances ? ( Identification of substances is not necessary ) .
This last question is essential to normal olfactory function .
2ND CRANIAL NERVE OPTIC NERVE
We examine four elements and in the mentioned order :
a. Visual Acuity b. Visual Field c. Colour vision d. Fundoscopy
A. VISUAL ACUITY
a. Always do this first .
b. Do what you did in your last MBBS using a Snellen’s Chart for assessment of distant vision and a Jaeger’s Chart for near vision .
The charts are often not available but you must know the process and principle so read them up again .
3 COLOUR VISION
a. You must know how to use Ishihara’s Chart in brief .
b. Once again ,it probably won’t be provided but you must know how it works 4. FUNDOSCOPY
a. You are definitely not expected to do this .
b. Just read Direct Ophthalmoscopy as a short note for now .
2. VISUAL FIELD .
a. You must know how to do this one .
b. The method we use is called Confrontation Perimetry .
( Nowadays at most clinics we use a machine to do Automated Perimetry ) .
c. The principle of the test is that we compare the patient’s field of vision with ours , assuming that our field is normal.
d. Without visual acuity the test is not possible , so we have to check this first . Also , for the same reason , spectacles , if present must be put on during the test .
e. Each eye is tested separately by the same process .
f. The patient and the examiner sit face to face at a ‘ hand shaking ‘ distance , about the length of their forearms combined.
f. Their faces and hence their eyes must be directly opposite and at the same level .
g. We test one eye at a time so we cover the other eye , the patient covers his own , as does the examiner .
h. The patient is instructed to :
1. Look at the examiner’s eye and fix his / her gaze there . 2. Not to look around by turning his / her eyes .
3. Not to turn his / her head .
i. The visual field of either is a large circle with four quadrants …superior nasal , inferior nasal , superior temporal and inferior temporal .
j .The examiner places his her finger tip at the extreme periphery of any one quadrant in the middle and brings it slowly towards the centre with an accompanying finger movement .
k. The patient is instructed to raise his hand / speak the moment he sees the finger .
l. If he/ she sees it with the examiner or earlier he/ she has a normal field , if later there is a peripheral field constriction which must be tested further later .
m . The finger is brought upto the centre as a search for any central scotomata . n. The test is repeated in all four quadrants of that eye and in the opposite eye .
Shall continue tomorrow ..
Cranial are favourite short cases. .. keep practicing .. Bye for now
EXAMINATION OF THE NERVOUS SYSTEM
CRANIAL NERVES Contd ….
3RD , 4TH AND 6 TH CRANIAL NERVES .. OCULOMOTOR , TROCHLEAR AND ABDUCENS NERVES
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The above three nerves are tested together because of their related functions and anatomy .
The following elements must be tested :
1. PUPILLARY REFLEXES
a. Light Reflex : Direct and Consensual b. Accomodation Reflex
2. MOVEMENT OF EXTRAOCULAR MUSCLES
3. NYSTAGMUS
This point is for seniors …just read a short note for now just incase …. Shall discuss it later when more important topics have been covered .
1. Pupillary Light Reflex . Direct and Consensual
Consider the following steps and precautions while testing ..
a. The room should be optimally illuminated .
A very brightly lit room will certainly cause bilateral pupillary constriction in both eyes (
assuming both are normal ) and your torch may not be able to elicit further constriction .
Also if the room is pitch dark you shall obviously see nothing .
So the room should be optimally lighted , not too light , nor too dark and try to stay away from direct sunlight or a bulb or tube .
b. The patient must look away at a far distant object / target .
Remember that both exposure to bright light and accommodation of the eyes cause pupillary constriction and you are attempting to test the first one , response to light . So you must avoid any unwanted accommodation from the patient .
The patient shall accommodate if he / she is looking at you or at any near object .. so to avoid any accommodation I instruct the patient to look at a far distant object . If the patient is still confused , give him/ her a specific target .
c. The torch used can be of white light or yellow light but must have a narrow beam ) ideally a pen torch ) . It should not light up the patient’s face or the entire room when switched on … That won’t do .
d. The torch must be focussed on the patient’s eyes from the side or from below .
This means that you turn on the torch holding it below the patient’s jaw or near his ar where he / she can’t see it and then gradually focus the beam on the patient’s eyes , one at a time .
e. No matter how hard you try to focus the beam one eye , the other eye receives a bit of torch light making separate assessment of direct and consensual reflexes impossible .
So the patient must put his hand ( left or right ) over the bridge of his nose to prevent light focused on one eye from spilling over onto the other eye .
f. Test for both sided direct and consensual light reflexes separately .
2. Accomodation Reflex
a. The patient must sit up .
b. The examiner must place his / her left hand over the patient’s forehead to fix the head and at the same time elevate both eyelids so as to observe both eyes properly .
c. Now the patient is asked to look at a distant object …as far as possible .
d. In this condition the examiner suddenly brings an object , say a pen or his / her fingertip in front of the patient’s face at in the midline , a little below the tip of the nose and asks the patient to quickly look at it and hold his / her gaze there .
e. This movement of looking at a near object obviously requires accommodation and two out of the three components of accommodation can be observed
1. Convergence of both eyes
2. Constriction of both pupils .
3. Testing the movement of the extraocular muscles .
a. The patient must be in the same posture as he / she was for accommodation … sitting up and head fixed and upper eyelids elevated by the examiner , usually with his / her left hand .
b. The examiner uses his other hand , sometimes holding a pen to focus on , to conduct the test .
c. The hand / pen is held about 2 ft from the patient’s face , in the midline about at the level of the pupils .
d. It is now moved slowly and in the horizontal plane to one side , left or right and the patient is instructed to follow the pen .
e.The pen is moved until an extreme of gaze is reached and the eyes can move no more .
f. The pen is held in that position for a few seconds while the examiner assesses the position of the two eyes …
He / she notes : Are the two eyes symmetrical in position or has one eye moved less than the other .
g. Then from that extreme position the examiner now moved his object to be focused on , the pen , upwards so that the patient has to shift his / eyes again but this time using a different group of yoke muscles .
h. Once again the examiner stops at the extreme and compared the position of the two eyes as before .
i. The process is repeated vertically downwards now and then the pen is moved horizontally across the midline to the opposite side , where all the testing is repeated .
j. Any abnormalities noted are analysed thereafter .
EXAMINATION OF THE 12 TH CRANIAL NERVE THE HYPOGLOSSAL .
a. Firstly , examine the tongue inside the mouth .
Look for :
1.atrophy … unilateral or bilateral
2. Spasticity
3. Fasciculations – the tongue being a mass of muscle with a thin cover of mucous membranes is the best place to see fasciculations .
b. The patient is asked to protrude his / her tongue Look again for :
1. Any deviation to one side
2. Any atrophy
( Do not look for fasciculations in this position… normal quivering movements can be misleading )
c. Now put on some gloves and very gently palpate the tongue comparing the right side with the left .
Feel for the excess softness of atrophy
d. The patient puts his / her tongue back inside , closes his / her mouth and pushes hard against his/ her cheek and you feel that pressure with your fingers placed on the cheek …you do it bilaterally to assess the power of the tongue .
Shall continue tomorrow .. Please practice
Bye for now
Respiratory examination : Things you need to know
5 TH CRANIAL NERVE TRIGEMINAL NERVE
It is a mixed nerve and we do consider 4 areas :
1. Facial sensation
2. Power of the muscles of mastication 3. Corneal Reflex
4. Jaw Jerk
1. Facial Sensation
a. The trigeminal nerve has 3 divisions : V1 – The ophthalmic
V2 – The maxillary
V3 – The mandibular
Each supplies a different part of the face with just about no overlap .
The ophthalmic division – The area supplied is bound in front by an imaginary line drawn from the tragus on either side upto the outer/ lateral canthus of the eyes on either side and bound behind by the coronal suture line .
The maxillary division supplies an area bound in front by that same imaginary line that binds the ophthalmic area in front and below by another imaginary line from the tragus to the angle of the mouth on either side .
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The mandibular division is just below the mandibular division is just below the maxillary and extends upto the jaw line ( of the maxilla ) .
b. We are to test all sensory modalities , ie pain , touch , temperature , vibration over all areas and compare them between both sides as done for the rest of the body .
c. We need a reference point which could be anywhere except the patient’s face and over the sternum for vibration sense .
d. Touch each area once ..that should be enough …hence 6 touches should do
e. For the mandibular area always touch close to the lips but not in the midline because a variable area near the angle of the mouth is supplied by C2.
f. Not straying too close to the midline where there may be some overlap applies to all 3 areas .
g. Refer to sensory testing for how to test sensation but at least test fine touch if not anything else .
2. Power of the muscles of mastication
a. Place your hands ( palms over the posterior part of both the patient’s cheeks at the same time so that you can feel and compare both mastoid muscles and ask the patient to clench his / her teeth .
At that moment feel and compare the contraction of both mastoid muscles .
b. Place both your hands over both temporal fossae ( ie sides of the forehead ) and as before ask the patient to clench his / her teeth while you feel and compare the contraction of the temporalis muscles on either side .
c. Place one hand , usually the right hand beneath the jaw and ask him / her to open his / her mouth against resistance from you and thus feel the power of both lateral pterygoids together .
d. Ask him / her to move his / her mouth from side to side against resistance applied by you with any one hand and feel the power of the medial and lateral temporal muscles together .
3. Corneal Reflex
a. The patient is asked to sit up preferably , though it may be managed lying down with some difficulty .
b. We use a clean piece of cotton drawn to a fine point .
c. We aim to touch the limbus ie the margin of the cornea and see blinking on either side … This is the corneal reflex .
d. However , it is very difficult to actually touch the corneal limbus without actually touching the eyelashes , because the lashes are protectively arranged to prevent large foreign bodies from reaching the eye .
To remedy this we place the other hand not holding cotton above and lateral to the eye to be tested above the forehead and ask him / her to look there ..this act of looking upwards and outwards created enough separation between the eyelids and eyelashes to allow the cotton wisp to touch the limbus .
Similarly , when testing the other eye change hands .
e. If you or any foreign body approaches a person’s eye it should close protectively …this is called ‘Menace Reflex ‘
To avoid this we bring the cotton to the limbus from the side or so that the patient cannot see the approaching cotton , and we must do it very swiftly .
4. Jaw Jerk
a. The patient must be sitting or supine , either shall do .
b. He / she must relax , ( perhaps close his/ her eyes ) and keep his / her mouth relaxed and partially open
c. We place one finger just below the lower lip , over the bone of the lower jaw . d. Now we tap it gently with our hammer .. normally nothing happens .
e. Abnormally , the mouth snaps shut …
8 TH CRANIAL NERVE VESTIBULO- COCHLEAR
a. You won’t be asked to test the vestibular part and assess vertigo because it is complicated .
b. You shall be asked to do
1. Rinne’sTest
2. Weber’s Test
3. Absolute bone conduction
and interpret the findings …
Read these as you have for your previous MBBS and have a 256 Hz tuning fork ready .
Shall continue tomorrow and shall probably finish cranial nerves …
Some of you may not have the links to the videos made by Arjun and his friends .. Please share the links among yourselves ..
It is difficult to understand the writing without a demonstration .
Bye for now …
7 TH CRANIAL NERVE FACIAL NERVE
This is a mixed nerve …the motor examination is more important to us than the sensory . We shall examine :
1. The muscles of facial expression.
2. Taste sensation over anterior two – thirds of the tongue .
1. Muscles of facial expression .
It is largely a demonstration. ..we demonstrate what we want and ask the patient to copy us while we assess the power of the muscle / muscles , comparing the right side with the left .
There are lots of muscles , we have standard clinical tests for a few muscles which are discussed here ..
The patient should be sitting throughout the examination ,though examination in a supine position is possible .
MUSCLES OF THE UPPER FACE
1. Frontal belly of the Occipito & frontalis
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a. We elevate both our eyebrows forcefully as to create wrinkles over our forehead and ask the patient to copy us .
b. We observe the wrinkles on the forehead and the elevation of the eyebrows , comparing both sides .
2. Corrugator Superciliary
a. We frown thus wrinkling the centre of our eyebrows and ask the patient to copy us .
b. We look for the wrinkles between the eyebrows and compare both sides .
3. Orbicularis oculi
a. We close our eyes forcefully thus wrinkling our eyelids and ask the patient to do the same .
b. It must be forceful.
c. We attempt to force open the patient’s eyelids with our small fingers ( never thumbs , always small fingers , use of thumbs is wrong because thumbs are much more powerful )
d. We tell the patient to attempt to keep his/ her eyelids closed against force from the examiner . MUSCLES OF THE LOWER FACE
- First just observe the face for any assymetry .
- Specially , look for any deviation of the angle of the mouth or difference in prominence of the
naso- labial folds on either side .
c. If none is observed , ask the patient to grin / show teeth forcefully . He/ she can copy you to avoid confusion .
This manoeuvre shall reveal any latent unilateral facial weakness . d. This involves multiple muscles of the face ,not just one or two .
2. Buccinator
a. Ask the patient to copy you and blow out his her cheeks .
b. Now simultaneously apply light yet sudden pressure over both cheeks with your hands and look for escape of air from one angle of the mouth , the weaker one .
3.
a.Contract your platysma ..this needs demonstration …I have no real words to describe this …please see the video or wait for our classes to start …( books call it the shaving muscle but none of us boys do that when we shave ♂).
b. Observe the patient , compare both sides .
Taste over Anterior two thirds of the tongue .
It is a simple yet clumsy test and is usually not asked for during the exam because if the arrangements required .
a. The test must be explained to the patient before you start . b. He/ she cannot talk during the test .
c. Have the following :
1. A card with the words
SWEET. SOUR SALTY and BITTER written on it .
2. Four bottles of clear solution , labelled but not shown to the patient . .with different solutions …one salty ,one e sweet , one sour and one bitter .
3. Four spatulas / applicators …one for each bottle .
4. A glass of water for the patient to wash his/ her mouth with during the test .
d. We test in the following sequence …
Sweet , Salty , Sour , Bitter … Because bitter can dominant and interfere with other taste sensations .
e. We use the applicator to touch the margin of the tongue with the sweet solution just behind the tip .
f. The patient shall point to the card , indicating what taste he/ she sensed . g. We make a note of that ….
h. The patient rinses his / her mouth with water .
i. The test is repeated with the same bottle ( sweet ) on the other side of the mouth . j. The process is continued with the other three bottles .
9TH AND 10TH NERVES GLOSSOPHARYNGEAL AND VAGUS
These two nerves are examined together ….they are anatomical and functionally intertwined and very difficult to assess separately .
Hoarseness of the voice , taught to you during ENT is exclusively due to vagal dysfunction . All other functions are overlapping .
We shall only examine the gag reflex .
1. First of all we must procure a swab stick ..
These are available at your microbiology department ,or you could buy one … Johnson’s buds aren’t long enough and please don’t make swab sticks at home …the cotton coming off could be a disaster .
2. Explain briefly and with reassurance about what you plan to do … gag can be very distressing for some people .
3. Your patient must open his / her mouth as wide as he / she can .
4. Your aim is to touch the posterior pharyngeal wall ,not the soft palate or the anterior tonsillar pillar . Touching either of these structures shall cause a gag reflex to occur but strictly speaking we must touch the oropharynx .
We cannot use a tongue depressor as this itself might cause discomfort or a gag .
We must hold the tip of the tongue lightly with a piece of gauze as we were taught in the ENT OPD .
5. We now touch the posterior pharyngeal wall not once but one both right and left sides .. because we must assess both right and left sided nerves .
6. If a gag occurs then it is normal and further assessment of these two nerves need not be done .
7. If gag is absent then the reflex arc has been breached …we need to find out where .
8. First we ask the patient if he/ she could feel the swab stick or not on either side . If no , then it was due to a sensory problem .
9. If pharyngeal sensation is intact however it must be due to a motor problem . In that case we must observe the movement of the uvula .
10 . Now we use a tongue depressor to visualise the uvula well .
11. We may use a torch here if necessary .
12. Now we ask him / her to say aah ..
13. However he/ she says it , any attempt at vocalisation causes palatal and hence uvular movement which should be bilaterally symmetrical.
If one side is weak there shall be a brief but dramatic deviation of the uvula to one side ,in this case the strong side , indicating weakness is present on the opposite side .
11 TH CRANIAL NERVE SPINAL ACCESSORY
We shall assess the spinal part of the accessory nerve which supplies the sternocleidomastoid and the trapezius , not the cranial part .
1. POWER OF THE STERNOCLEIDOMASTOID
a. The left sided sternocleidomastoid rotates the head to the right but tilts the head to the left ; similarly the right sternocleidomastoid muscle does the opposite .
We shall assess strength of this muscle based on the rotation , not the tilt .
b. For the the left sternocleidomastoid we :
1. Stand in front of the patient .
2. Place our left hand on his / her right cheek .
3. Use our index finger and thumb of the right hand to palpate the belly of the left sternocleidomastoid muscle .
4. Ask him / her to rotate his / her head to the right against resistance offered by you by attempting to prevent the rotation with pressure applied on the right cheek .
5. We note the strength of the muscle while contracting and feel the muscle too .
6. This is repeated for the right sternocleidomastoid using opposite hands .
7 . Lastly , we stand to one side , place a hand
on his / her forehead and ask him / her to flex his neck against resistance ,while we note the force of contraction .
2. POWER OF THE TRAPEZIUS a. We stand behind the patient .
b. We place our palms over the medial aspect of each shoulder , right palm on right shoulder and left on left .
c. The hands should be placed medially next to the root of the neck and hence over the trapezii on either side , not laterally over the shoulder joint and deltoid .
d. Now we simply ask him/ her to shrug his / her shoulders forcefully against resistance offered by you and we compare the strength of contraction of either trapezii .
Have finished clinical examination somewhat .
We will post different diseases which you must know for your examination. We shall mix theory and practical of each . Plus I shall try to include general survey and clinical problems .
Bye for now ..
- MEDICINE : Spotters
- Kocher Maneuver for Shoulder Reduction
- ABDOMINAL EXAMINATION: THE COMPLETE GUIDE
- Complete Guide to Examination of the Nervous System
- Cardiovascular Examination: The Complete Guide
